Treatment of Post-Prostatectomy Incontinence

Post-prostatectomy stress incontinence is one of the most feared complications of radical prostatectomy with a major impact on quality of life, physical activity and social well- being. The basic evaluation of PPI (post-prostatectomy incontinence) comprises medical history, physical examination including genital and digital rectal examination, objective assessment of symptoms (pad weight test, voiding diary), urinalysis, ultrasound for post-void residual volume, assessment of influence on quality of life and assessment of desire for treatment.

Conservative management is recommended as first line treatment within the first six to 12 months of PPI, and includes physiotherapy and pharmacotherapy. If intensive conservative treatment fails and the persistent PPI affects quality of life, surgical therapy is recommended. Generally, surgical treatment should be offered if the incontinence status is stable despite intensive conservative treatment, and up to 10% of patients with PPI undergo surgery.

According to several guidelines, the artificial urinary sphincter (AUS) is still the treatment of choice for persistent moderate to severe SUI (stress urinary incontinence). Long-term success rates (zero to one pad/day) of 59% to 90% can be achieved. Complications associated with AUS implantation include erosion, mechanical failure and infection. In addition, periodic revisions may be necessary. The revision rates due to mechanical failure are 8% to 45% while those due to non- mechanical issues (eg erosion, urethral atrophy and infections) range from 7% to 17%.

In the last decade several new minimally invasive sling systems for male SUI were introduced. According to current guidelines, slings are an alternative for men with persistent SUI with the best results in non-irradiated patients with mild to moderate SUI. After three years the success rate was found to be 77% (53% no pad or one security pad).  In irradiated patients the sling showed reduced treatment success with dry rates between 25% and 53%. After implantation physical activities should be reduced to a minimum for eight to 12 weeks to reduce the risk of postoperative sling dislocation. Severe complications including explantation are rare. The main postoperative complication is transient acute postoperative urinary retention (up to 21%) requiring temporary re-catheterization.

Bulking agents can also be used and currently, the most commonly used bulking agents are dextranomer/hyaluronic acid copolymer and poly- dimethylsiloxane. Early failure rate is still about 50% and initial success in continence decreases with time.  For satisfactory intermediate results re-injections are necessary. Due to the low success rates, bulking agents should only be used in highly selected patients with mild SUI.

Radical prostatectomy is the main causative factor for male SUI. For early PPI, within the first year after radical prostatectomy, non-invasive conservative treatment with PFMT (pelvic floor muscle training) is recommended as it hastens the return to continence. If conservative treatment fails after an intensive treatment period of at least six to 12 months, surgical therapy is recommended. The AUS is still the treatment of choice for moderate to severe PPI. However, male slings are an alternative surgical option especially for mild to moderate PPI with promising results.